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Tue, November 1, 2011
Peripheral Neuropathy: When Toes are Numb and Hands Tingle
Peripheral neuropathy is a general term for disorders of the nerves that serve the farthest reaches of the body such as the feet, legs, and hands. These nerves form the peripheral nervous system or the “electrical wiring system of the body.” Short circuits in these “wires” distort the messages that travel back and forth to the brain. This results in abnormal sensations and symptoms such as numbness, tingling, burning pain, weakness, restlessness of legs, and loss of balance.

What causes peripheral neuropathy? There are several known causes for this debilitating condition.

A Few Common Offenders

Diabetes Mellitus

Diabetes is a leading cause of peripheral neuropathy. More than half of those with this disorder develop nerve involvement. Nerve involvement (neuropathy) can occur at any time in the course of this metabolic condition but the risk increases with longer duration of diabetes. The symptoms of neuropathy are more common in those who have difficulty controlling their blood sugar, especially when diabetes is associated with high blood pressure, elevated cholesterol, and regular alcohol use. Diabetes can also be an underlying cause of carpal tunnel syndrome.

There is increasing evidence that indicates that neuropathy can occur even in the pre-diabetic stage. Previously known as “borderline” diabetes, pre-diabetes refers to a state of higher than normal blood sugar levels in the body, but not high enough to be diagnosed as overt diabetes. Without treatment, this may progress to overt diabetes and peripheral neuropathy. Although often asymptomatic, tingling, pain, burning or pins-and-needle sensation in the limbs (especially in the feet) may occur as early warning symptoms.

Thyroid Disease

Although not a common cause, abnormal thyroid hormonal levels are known to result in neurologic problems including peripheral neuropathy (which may occur despite adequate treatment). However, the most common neuropathy associated with an underactive thyroid (hypothyroidism) involves the median nerves across the wrists leading to carpal tunnel syndrome. Weakness due to muscle involvement is also a common complaint of patients with thyroid disorders.

Nutritional Deficiencies

Several nutrients are required for optimal nerve function. A common cause of nutritional neuropathy is Vitamin B12 deficiency. A strict vegetarian diet or diets lacking in eggs, dairy products, fish and red meat may promote B12 deficiency. It should be noted that food supplements such as shiitake mushrooms and fermented soy products do not contain enough of the active form of this vitamin.

Toxins and Medications

Neuropathy can result from exposure to environmental toxins such as solvents, insecticides and fertilizers. Long-term heavy alcohol use is also a known cause of peripheral neuropathy. It is believed that alcohol interferes with nerve function either directly or by causing a nutritional deficiency.

Connective Tissue Disorders

The arthritis family of disorders including rheumatoid arthritis, lupus erythematosis are also known to cause peripheral neuropathy.

Cancer

Disturbance of sensation or loss of strength in the limbs may predate the other signs of cancer. Neuropathy can also occur as a side-effect of medications used for treating cancer (chemotherapy).

Heredity

There are certain types of neuropathies that are inherited. These usually show up early in life and tend to progress slowly over time.

Other Causes

Chronic kidney failure and infections such as Hepatitis B or C, HIV and Lyme disease have also been known to cause peripheral neuropathy.

Now let’s wear the Sherlock Holmes hat!

How does one investigate this condition? The neurologic evaluation is geared toward identifying a treatable cause for the neuropathy. Hence certain blood and urine tests are obtained as part of this screening process.

The symptoms of neuropathy are also commonly evaluated with an EMG (electromyography or muscle and nerve testing). This procedure has two components: a nerve conduction study which measures the speed of conduction of electrical stimuli applied along the nerves and a needle study that assesses muscle function by displaying their electrical activity on an oscilloscope. Apart from confirming the diagnosis, the test helps define the types and severity of nerve dysfunction. Trying to getting to the bottom of it all can be quite challenging. And a reason for the neuropathy may not always be evident.

Are there any yardsticks for measuring outcome?

Despite the best of treatment approaches, some patients with peripheral neuropathy tend to progress. Worsening of symptoms such as pain is however not a good indicator of progression of this condition. Some forms of neuropathy are not painful and pain may vary in frequency and severity. Also the level of pain tolerance varies from person to person. If sometimes the pain is better, it may not mean that the neuropathy has improved. Over time, the underlying disease process, if left untreated, may cause gradual loss of nerve fibers. This may result in increased numbness and sometimes improvement in pain. In this case, less pain means further worsening of the neuropathy.

Numbness on the other hand is a reliable symptom to measure improvement. Increased numbness suggests progression of neuropathy. However, the most reliable symptom to follow is weakness. If there is weakness and this is improving, then the neuropathy is more likely getting better. Neurologic evaluation would help in clarifying this further.

Can we beat Neuropathy?

The saying “An ounce of prevention is better than a pound of cure” applies quite well in managing peripheral neuropathy. For example, with early identification and measures to control blood sugar, patients with pre-diabetes may be able to reduce the risk or delay the onset of severe nerve disease.

The key to prevention of diabetic nerve disorder is maintaining tight control of the blood sugar at normal or near-normal levels. Hopefully, this will help reduce the symptoms of neuropathy provided other associated causes have also been addressed.

It is hoped that by treating the underlying cause, the progression of peripheral neuropathy can be halted. If environmental toxins or alcohol are found to be the cause, eliminating these would also help limit the impact of peripheral neuropathy.

Due to the reduced sensation, there is risk of injury. To help prevent complications, people with neuropathy need to examine their hands, feet and legs every day (look for and prevent injury such as cuts and bruises), check the temperature of bath water to prevent burns, take care of their nails regularly and wear properly fitted, comfortable shoes.

Physical therapy to strengthen weakened muscles and balance training with assisted devices are quite often part of the comprehensive management of peripheral neuropathy.

While there are no magical potions or permanent cures for several types of neuropathy there are many medications available to relieve neuropathic pain. Selecting one requires carefully weighing factors such as the underlying condition, associated features and the benefits versus adverse effect profile of the medication.

Are there any holistic approaches?

Over the years, various nutritional supplements have been claimed to benefit peripheral neuropathy. These include Thiamine, B12, Omega-3 and N-acetyl Cysteine. A few studies have shown that antioxidants such as alpha-lipoic acid may relieve symptoms (pain and paresthesias) of diabetic neuropathy. A note of caution: due to potential interactions with medications and side effects, any food supplements or herbs should be taken under the guidance of a health care provider.

The good news for those struggling with neuropathy is that there are many options available today for managing their condition.

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